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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342701097
Report Date: 01/04/2024
Date Signed: 01/04/2024 03:57:40 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/28/2023 and conducted by Evaluator Tung Truong
COMPLAINT CONTROL NUMBER: 27-AS-20231228130547
FACILITY NAME:SKYPARK MANORFACILITY NUMBER:
342701097
ADMINISTRATOR:RICHARDSON, SHERRYFACILITY TYPE:
740
ADDRESS:5510 SKY PARKWAYTELEPHONE:
(916) 422-5650
CITY:SACRAMENTOSTATE: CAZIP CODE:
95823
CAPACITY:144CENSUS: 78DATE:
01/04/2024
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Susan McClureTIME COMPLETED:
04:15 PM
ALLEGATION(S):
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Facility has an infestation of rodents
Facility is unclean
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Tung Truong conducted an unannounced complaint visit on 1/4/2024 at 1:00 pm to investigate the allegations listed above. LPA met with Assistant Administrator, Susan McClure and explained the purpose of today's visit.

During today’s visit, LPA toured the facility and conducted interviews. Based on observations, interviews, and records review, it was determined that the facility has an infestation of rodents. LPA observed there were rat feces in rooms #136, 145 and 146. In addition, LPA observed the carpet is dirty and there were debris and rat feces on the floor in multiple rooms.

As a result of the investigation, the preponderance of evidence standards has been met, therefore, the above allegation(s) is/are found to be SUBSTANTIATED. Per California Code of Regulations, Title 22 Division 6, Chapter 8, deficiencies are being cited on the attached 9099-D during this visit.

Exit interview held, Appeal Rights discussed, copy of report given.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Tung TruongTELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:

DATE: 01/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 27-AS-20231228130547
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: SKYPARK MANOR
FACILITY NUMBER: 342701097
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/04/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/18/2024
Section Cited
CCR
87307(d)(2)
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87307(d)(2) Personal Accommodations and Services: The following space and safety provisions shall apply to all facilities: The premises shall be maintained in a state of good repair and shall provide a safe and healthful environment.
This requirement was not met by:
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The facility has a contract with Clark Pest Control Company to conduct a bi-weekly pest treatments. Administrator agrees to conduct training on reporting pest/bug/rodent infestations by POC Date 01/18/2024. Administrator will email training materials by 01/18/2024.
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Based on interviews, observation, and file reviews, the licensee did not ensure the facility was clean/sanitary and healthful environment. The facility has a rodent infestation throughout the facility. This poses a potential health and safety risk to residents in care.
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Type B
01/18/2024
Section Cited
CCR
87303(a)
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87303(a) Maintenance and Operation...The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
This requirement was not met by:
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The facility administrator agrees to conduct a maintenance and operation training for staff by POC day 01/18/2024. Administrator will email training materials by 01/18/2024.
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Based on interviews and observation, the licensee did not ensure the facility is clean, safe, sanitary and in good repair at all times. There were rat feces and debris found in resident room #145. This poses a potential health and safety risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Tung TruongTELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:

DATE: 01/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2